Review Article

Classifying thoracolumbar fractures: role of quantitative imaging

Fernando Ruiz Santiago1, Pablo Tomás Muñoz2, Elena Moya Sánchez2, Marta Revelles Paniza2, Alberto
Martínez Martínez1, Antonio Luis Pérez Abela3
1
Radiology Department, Hospital of Traumatology, Carretera de Jaen SN, Granada 18014, Spain; 2Radiology Department, Ciudad Sanitaria Virgen
de las Nieves (Hospital Complex University of Granada), Avenida de las Fuerzas Armadas 2, Granada 18014, Spain; 3Traumatology Department,
Hospital of Traumatology, Carretera de Jaen SN, Granada 18014, Spain

Correspondence to: Fernando Ruiz Santiago, MD, PhD. Chairman of Musculoskeletal Radiology, Hospital of Traumatology, Carretera de Jaen SN,
Granada 18014, Spain. Email: ferusan12@gmail.com.

Abstract: This article describes different types of vertebral fractures that affect the thoracolumbar spine
and the most relevant contributions of the different classification systems to vertebral fracture management.
The vertebral fractures types are based on the three columns model of Denis that includes compression,
burst, flexion-distraction and fracture-dislocation types. The most recent classifications systems of these
types of fractures are reviewed, including the Thoracolumbar Injury Classification and Severity score (TLICS)
and the Arbeitsgemeinschaft für Osteosynthesefragen Spine Thoracolumbar Injury Classification and
Severity score (AOSpine-TLICS). Correct classification requires a quantitative imaging approach in which
several measurements determine TLICS or AOSpine-TLICS grade. If the TLICS score is greater than 4, or
the AOSpine-TLICS is greater than 5, surgical management is indicated. In this review, the most important
imaging findings and measurements on radiography, multidetector computed tomography (MDCT) and
magnetic resonance imaging (MRI) are described. These include degree of vertebral wedging and percentage
of vertebral height loss in compression fractures, degree of interpedicular distance widening and spinal canal
stenosis in burst fractures, and the degree of vertebral translation or interspinous widening in more severe
fractures types, such as flexion-distraction and fracture-dislocation. These findings and measurements are
illustrated with schemes and cases of our archives in a didactic way.

Keywords: Vertebral fractures; thoracolumbar trauma; spinal injuries; plain radiography; computed tomography

Submitted Jul 03, 2016. Accepted for publication Oct 22, 2016.
doi: 10.21037/qims.2016.12.04
View this article at: http://dx.doi.org/10.21037/qims.2016.12.04

Introduction challenging and, as a result, diagnostic imaging usually plays

an essential role in their exact diagnosis and appropriate
Almost 90% percent of all spinal injuries involve the
management (6). The aim of this article is to review the
thoracolumbar (TL) region (1). More than 50% of thoracic
role of different imaging methods in studying TL fractures,
and lumbar fractures occur between T11 and L1 (2), while
emphasizing the role of the radiologist in classifying and
25–40% of the factures affect the rest of the dorsal spine
quantifying the severity of these fractures.
and 10–14% the rest of the lumbosacral spine (3). Fifty
percent of TL fractures are unstable and can result in
significant anatomic injury and deformity (4). Neurological Imaging TL fractures: which technique should I
deficit is present in 20–40% of TL fractures with most use?
paraplegics sustaining trauma between the T11 to L2 spinal
Radiography
segment (4,5).
Clinical assessment of patients with TL fractures is often Radiographs are the adequate starting modality for

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Quantitative Imaging in Medicine and Surgery, Vol 6, No 6 December 2016
A B
C D
Figure 1 Interspinous distance measurement. (A) Sagittal
multiplanar reformat (MPR) from multidetector computed
tomography (MDCT). The gap between the spinous processes
is measured. A 14 mm interspinous widening is consistent with
posterior ligamentous complex (PLC) tear. (B) interspinous
distance is measured in AP radiographs by measuring the distance
between the upper borders of the spinous processes projection of
contiguous vertebrae. Percentage of widening of the interspinous
distance can be calculated with the following formula, where
A is the interspinous distance of the normal superior vertebra,
B is the interspinous distance at the fractured vertebra and C
is the interspinous distance of the normal inferior vertebra:
 (A + C) 
B - 
 2  × 100 (C) Sagittal MPR in MDCT
% of widening =
(A + C)
2 is the presence of a concave depression of the endplate.
shows 7 mm interspinous widening suspicious of PCL tear that was
ruled out by MRI (arrow in D).
patients who have sustained a low-energy trauma. AP and
lateral views are usually performed. Both projections are
useful in assessing vertebral height and the presence of
fracture lines. The AP view allows the measurement of the
interpedicular distance, which is increased in burst fractures,
and the interspinous distance, which is increased in
posterior ligamentous complex (PLC) injuries. These values
can be reported as millimeters or as a percentage relative
to adjacent normal levels. Regarding interspinous distance,
variations of up to 7 mm are considered as normal (7).
© Quantitative Imaging in Medicine and Surgery. All rights reserved.
773
Calculation of the percentage of the spinous processes
widening compared with adjacent normal levels is also
useful, with 20% of widening being considered as sign of an
unstable PLC, requiring surgical treatment (Figures 1,2) (8).
On lateral radiographs the two main parameters to be
measured are vertebral height loss and kyphotic deformity (6)
(Figure 2). Kyphosis is the most common deformity observed
in TL spine fractures and there are several ways to quantify
it. Local vertebral kyphosis angle is measured between
the tangent to the upper endplate and the lower endplate
of the injured vertebra. We have to be reminded that
vertebral wedging is not always synonymous of vertebral
fracture. In normal children and adults, the vertebral body is
anteriorly wedged from T1 through L2 (peak at T7), non-
wedged at L3, and posteriorly wedged at L4 to L5 (peak at
L5) (9). The superior limits of normal wedging have been
reported in the literature as a ratio between the anterior
and posterior vertebral height. In asymptomatic adults, this
limit can reach 10º (10) and 11º in children (11), although
other schemes broaden this limit up to 20º–25º (12,13).
Nevertheless, although fractures without vertebral deformity
or wedging can occur, a vertebral height reduction >15%
is considered by other authors as one of the morphometric
criteria required for radiographic diagnosis of an incident
vertebral fracture (14). This variability indicates a lack of
consensus on the exact definition of an osteoporotic vertebral
fracture by spinal radiography. These cutoff points are
used to avoid the inclusion of other non-fractures entities
which lead to reduced vertebral body height in the absence
of fracture, such as physiological wedging, short vertebral
height (SVH), Scheuermann’s disease-Schmorl’s nodes,
degenerative scoliosis or Cupid’s bow deformity (15). Another
morphological criterion for osteoporotic vertebral fracture
Therefore, a reduction greater than 15% in the anterior
vertebral height without endplate depression is categorized as
non-osteoporotic SVH, which includes normal variation in
height or developmental abnormalities (16).
Orthopedic surgeons may also make treatment decisions
based on other measurements, such as regional kyphosis or
the sagittal index. Regional kyphosis is the angle defined
by the tangent to the upper endplate of the vertebra
overlying the fracture and the tangent to the lower endplate
of the vertebra underlying the injured vertebra. This is
the recommended method by the Spine Trauma Group
Study in quantifying kyphotic deformity due to its higher
reliability (17).
The sagittal index (SI) is defined as segmental kyphotic
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774 Ruiz Santiago et al. Role of imaging in thoracolumbar fractures

A B C

D E F

Figure 2 Radiological measurements in plain film radiography. (A) Interpedicular distance measured from the closest point of the medial
aspect of both pedicles. Percentage of widening of the interpedicular distance can be calculated by the following formula, where A is the
interpedicular distance of the normal superior vertebra, B is the interpedicular distance at the fractured vertebra and C is the interpedicular
 (A + C) 
B - 2 
distance of the normal inferior vertebra: % of widening =   × 100 ; (B) Anterior vertebral height. The percentage of vertebral
(A + C)
2
height loss can be calculated by the following formula, where A is the height of normal superior vertebra, B is the height of the fractured
 (A + C) 
 - B
 2  × 100 ; (C) Wedge fracture of
vertebral body and C is the height of normal inferior vertebra: % of vertebral height loss =
(A + C)
2
T12; (D) local Kyphosis is the angle between both endplates of fractured vertebra; (E) regional kyphosis is the angle between the upper
endplate of the vertebra overlying the fractured vertebral body and the lower endplate of the vertebra underlying the fractured vertebral
body; (F) segmental kyphosis (SK) is the angle between the inferior endplate of the injured vertebra and the inferior endplate of the
overlying vertebra (segment = injured vertebra + overlying disc).

deformity minus the baseline sagittal contour in the
segment with the fractured vertebral body. The segmental
kyphosis is the angle between the inferior endplate of the
injured vertebra and the inferior endplate of the overlying
vertebra. The baseline sagittal contour in each vertebral
segment arbitrarily amounts to +5° for the thoracic region,
0° T12–L1 and −10° for the lumbar spine segments. The
normal index is 0 (18).
Multidetector computed tomography (MDCT)
In most centers, spine CT is nowadays included as
the starting modality in the imaging protocol of high
energy trauma, not only if back pain is present, but in all
cases as part of ruling out bone fractures and associated
thoracoabdominal injuries. Long bone fractures and
traumatic brain injury can act as distracting injuries, and

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Quantitative Imaging in Medicine and Surgery, Vol 6, No 6 December 2016 775

A B C

D E F

Figure 3 Radiological measurements with multidetector computed tomography (MDCT). (A-C) Sagittal to transverse diameter ratio
decrease is compared with the ratio of the superior and inferior normal vertebrae; (D-F) the canal area decrease can be calculated by the
following formula, where A is the canal area at the normal superior vertebral body, B is the canal area at the fractured vertebral body, and C
 (A + C) 
 - B
is the canal area normal inferior vertebral body: % canal area decrease = 
2  × 100 .
(A + C)
2

therefore, total spine CT is mandatory in these cases. In
poly-trauma patients, demonstration of a vertebral fracture
in a segment of the spine is indication of scanning the whole
spine with CT because up to 20% of these patients show
non-contiguous vertebral fractures (19).
MDCT is also indicated in cases of low energy trauma with
normal radiographs, if clinical suspicion persists. A tailored
CT scan covering the painful segment is recommended due
to the low sensitivity of radiography for detecting vertebral
fractures, ranging from 33–77%, according with the affected
level, being lower in the upper thoracic spine and higher in
the lumbar spine (6,20). When fractures are demonstrated on
radiographs of patients with low energy trauma, we advocate
to perform a CT scan including at least two vertebrae up and
below the fracture, because it is well known that radiographs
underestimate the severity of fractures, including instability,
or misdiagnose burst fractures as anterior compression
fractures (21,22). Therefore, radiographs alone cannot be
used for surgical planning and additional CT scanning is
mandatory for accurate fracture classification and treatment-
decision making (23).
All measurements performed by plain film radiographs can
be reproduced to better advantage by MDCT. Measurements
of canal dimensions are also more accurate. The sagittal-to-
transverse canal diameter ratio, the canal total cross-sectional
area, and the percent of canal stenosis are considered the most
useful parameters in predicting neurological damage (17)
(Figure 3). Comparison is performed with the pre-injury canal
diameter calculated from the intact levels above and below the
fractured vertebra. The ratio of sagittal to transverse diameter
at the level of the injury has been shown to be significantly
decreased in patients with neurologic deficit, mainly due to
increase of the interpedicular transverse diameter that leads
to a more ellipsoid vertebral canal shape. A ratio under 0.40 is
seen in most of the patients with neurologic symptoms (24).
Smaller cross-sectional areas can be tolerated at caudal levels
without neurologic deficit. Previous research has concluded
that the percentage of canal stenosis needed for neurologic
compromise varies according localization. Significant risk is
present when canal narrowing is ≥35% at T11 to T12, ≥45%
at L1 and ≥55% at L2 and below (25).
In fracture-dislocation the degree of translation of
vertebral body is also measured. Vertebral translation
greater than 3.5 mm has been reported to be associated with

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776
A B
D E
Figure 4 Three columns Denis’ model. (A) Axial scheme; (B) sagittal scheme of compression fracture; (C) sagittal scheme of burst fracture; (D)
sagittal scheme of three columns Denis’ model; (E) sagittal CT of compression fracture; (F) sagittal CT of burst fracture.
PLC injury (7).
The sensitivity of CT for depicting TL fractures ranges
from 95–100% (26,27). It is also more accurate than
magnetic resonance imaging (MRI) for detecting fractures
involving the posterior elements, and for demonstration of
the size and location of loose osseous fragments (27).
Magnetic resonance imaging
Although neurological status is usually assessed clinically,
MRI is recommended to determine the exact location and
extent of the damage. From a radiological point of view
medullary lesions are graded into three types based on T2
weighted images: (I) representing cord hemorrhage, shows
initial hypointensity on MRI and prognosis is poor; (II)
representing cord edema, shows initial hyperintensity and
have the best prognosis; and (III) considered a contusion
or small central hemorrhage surrounded by edema, shows
a mixed pattern and intermediate prognosis (28). MRI can
also quantify the extent of anatomical injury. Spinal cord
edema confined to 1 vertebral segment or less has a much
better prognosis for neurological recovery than extending
over a longer segment (29).
Because PLC injury, even in the absence of neurological
damage, may also indicate surgery, MRI is needed when
clinical exam or CT do not clearly assure the integrity of
© Quantitative Imaging in Medicine and Surgery. All rights reserved.
Ruiz Santiago et al. Role of imaging in thoracolumbar fractures
C
F
the PLC. Rupture of the ligaments is depicted as frank
interruption of a normally dark ligament replaced by
high signal intensity fluid. MR imaging accuracy has been
reported to be higher for detecting supraspinous ligament
and ligamentum flavum injuries, and slightly lower for
interspinous ligament and facet capsular injuries (30).
Types of traumatic vertebral fractures
Quantification of TL fracture severity based on imaging
is paramount for accurate classification into fracture type
and appropriate treatment guidance. Denis’ three columns
model is helpful for defining the basic types of fractures (31).
Compression fractures are characterized by an isolated failure
of the anterior column. Therefore, the posterior vertebral
wall and the spinal canal are intact (Figure 4).
Burst fractures are the result of compression mechanisms
or as part of a hyperflexion-extension or rotation injury (32).
The anterior and middle column are disrupted secondary
to axial loading. Its radiographic signs are disruption of the
posterior vertebral body wall, loss of the posterior vertebral
height with retropulsion of the posterior vertebral body
margin into the canal, and an increased interpedicular
distance (Figure 4).
In flexion-distraction fractures all three columns are
affected. Distraction means separation of two parts, the
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Quantitative Imaging in Medicine and Surgery, Vol 6, No 6 December 2016
A B
C D
Figure 5 Flexion-distraction fractures. (A) Sagittal scheme. (B)
Sagittal CT showing interspinous widening and the horizontal
fracture of the posterior arch (C). (D) Radiograph showing the
empty body sign and the horizontal fracture of the pedicle (arrows).
middle and posterior column, with the anterior column
acting as a pivot. This mechanism is associated with a
high incidence of intra-abdominal injuries. Their typical
radiographic findings include interspinous widening,
transverse fractures through the pedicles and/or other
posterior elements and increased height of the posterior
vertebral body and/or posterior intervertebral disc. On the
AP view, interspinous widening is shown as the “empty
vertebral body sign” (33) (Figure 5).
Fracture-dislocation injuries are usually the result of
multidirectional forces, including compression and/or
distraction in combination with some degree of shear or
rotation (34). The diagnosis can be made with radiographs
based on the observation of vertebral displacement of
dislocated facets, although CT shows to better advantage
the displacement and canal stenosis. Dislocated facets can
also be demonstrated on axial images by analyzing the
naked facet secondary to the loss of the normal relationship
between facets (35). These fractures are extremely unstable
and are associated with the highest incidence of neurologic
injury (Figure 6).
Non-traumatic vertebral fractures
With population ageing only 14% of the fractures are
© Quantitative Imaging in Medicine and Surgery. All rights reserved.
777
A B
C D
Figure 6 Fracture-dislocation fractures. (A) Sagittal scheme; (B)
sagittal CT of a fracture dislocation; (C) sagittal CT of locked facet
(arrow); (D) axial CT showing naked facets (arrows).
traumatic, while most of the fractures (86%) are due to low
energy trauma: 83% followed moderate or no trauma in
conditions of general fragility of bone, mainly in osteoporotic
patients, being classified as insufficiency fractures, and 3%
are pathologic, secondary to osseous involvement of a focal
lesion, mainly tumors (36).
Low energy fractures can be classified as insufficiency
fractures or pathologic fractures. When this is not possible,
imaging guided biopsy may be indicated. In addition, even
when imaging indicates a pathologic fracture, biopsy is still
needed. Several radiological signs have been described to
support this differential diagnosis, with MRI playing the
main role in this task due to its capacity to detect fractures
before radiographic morphologic changes appear (14).
Acute osteoporotic vertebral fractures tend to show a
band-like pattern of subchondral edema and, quite often, the
linear pattern of the vertebral fracture can be depicted inside
the edema. A retropulsed bone fragment and the presence of
intra vertebral cleft are characteristic of benign compression
fractures. Chronic vertebral compression fractures are
characterized by morphologic changes with recovery of
normal signal of the bone marrow (Figure 7) (37).
Pathologic fractures may show complete substitution of
normal bone marrow or, when incomplete, tend to show
and nodular or patchy pattern. Morphologic signs are a
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778
A B
D E
Figure 7 (A) Sagittal MDCT with intravertebral cleft (anterior arrow) and retropulsed bone margins (posterior arrows). Sagittal T1 (B) and
STIR (C) of band like edema in acute osteoporotic fracture. (D) Chronic osteoporotic fracture with vertebra deformity but normal marrow
signal. Sagittal T1 (E) and STIR (F) of pathologic metastatic fractures with convex vertebral borders.
convex vertebral border, due to vertebral cortex expansion
by a growing tumor, and the presence of an asymmetric
paravertebral mass (Figure 7) (38).
Classification systems
To decide management, accurate classification of the
fracture is critical. Understanding the historical evolution
of classification systems is useful in achieving this purpose.
Before X-ray discovery in 1895, spinal fractures were
classified based on the presence or absence of neurological
injury (39).
Since Boehler first proposed his injury categories in
1929, after the spread of radiography use, many advances
have been achieved in the understanding of fracture
mechanisms, imaging and classification. These systems were
based on the anatomy and mechanism of the fractures (40),
instability and posterior element integrity (41,42).
Holdsworth was the first author introducing the column
concept in 1963. He divided the spine into an anterior and
posterior column, separated by the posterior longitudinal
ligament, considering this ligament as the most important
for spinal stability. Therefore, compression and burst
fracture, that share the same axial load failure mechanism,
were considered stable because the posterior column was
© Quantitative Imaging in Medicine and Surgery. All rights reserved.
Ruiz Santiago et al. Role of imaging in thoracolumbar fractures
C
F
not damaged (43).
The novel two columns model of Holdworth was
challenged by other authors that proposed a three columns
model, pinpointing the posterior vertebral wall as the mainstay
of spinal stability (44,45). The most popular and widespread
of these works was Denis’ three columns concept (31).
The posterior column was the same as that described by
Holdsworth, while the middle column included the posterior
wall of the vertebral body, the posterior annulus fibrosis and
the posterior longitudinal ligament. Although this system
is considered useful to explain the different types of spinal
fractures, it is not as successful in predicting spinal stability.
In fact, the classification of all fractures with involvement of
two of the three columns as unstable is considered by many
as an oversimplification since it is well-known that additional
criteria are needed to classify two-column burst fractures
as stable or unstable. Biomechanical cadaveric studies
demonstrated that the integrity of the posterior column was
a far better indicator of fracture stability than the integrity of
the middle column (46).
Several classifications systems contributed to the
understanding of TC lumbar fractures, such as the one by
Mcafee (47), deepening in the concept of instability, or the
AO-Magerl system, which is comprehensive but complex (32).
McCormack and Gaines in 1994 introduced the load sharing
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A B C

D E F

Figure 8 Short segment instrumentation failure. This patient suffered a L1 burst fracture and scored 8 on the load sharing classification
system. Apposition of bone fragments: 3 (A); Vertebral body comminution: 3; an intra-vertebral cleft or cyst is also present (arrow) (B).
Kyphotic correction: 2 (C). After several months kyphotic deformity increased (D). In another patient, local kyphosis changed from 15º in
standing radiograph (E) to 0º in CT scan (F) and was diagnosed of unstable vertebral body fracture.

classification system to predict the risk of implant failure
after short segment posterior fixation of TL fractures (48).
The factors influencing fixation failure include the amount
of vertebral body comminution on sagittal images, the
apposition of bony fragments seen on axial images and the
amount of kyphotic deformity correction by comparing pre-
and postoperative films. Each factor scores 1 to 3 according
to severity. Scores ≥7 indicate the need of longer multilevel
posterior fixation or anterior vertebral body reconstruction
(Figure 8). Radiologist are able to quantify comminution
and apposition of bony fragments on CT images. They
could also predict the capacity of kyphotic correction, even
before surgery, in cases for which comparison between CT,
performed in extension, and radiography, performed in the
sitting, lateral decubitus or standing position, were available.
Kyphotic correction is a sign of vertebral instability and
may influence the type of surgical treatment (49).
The Thoracolumbar Injury Severity Score (TLISS)
classification was created by the Spine Trauma Study Group
in 2005 (50). Three parameters are scored in order to classify
patients who require surgical or non-surgical management.
These parameters are mechanism of injury, neurological
status and integrity of the PLC. Nevertheless, after a
study by the same group, a modification of the system was
proposed in which the mechanism of injury was changed by
the type of fracture in an attempt to improve intra and inter-
observer reliability. It is supposed that injury morphology is
easier to elucidate than having to infer the injury mechanism
from static radiological studies. This new system is called
the thoracolumbar injury classification and severity score
(TLICS) (51).
A score <4 points is indicative of medical treatment, >4
indicative of surgical management, while if it is =4 points
the decision is based on surgical modifiers. Factors that may
indicate surgical management include severe local kyphosis
or vertebral collapse, open fractures, obesity that precludes
wearing of a brace, or, in case of poly-trauma, need of early
mobilization. Factors against surgery include severe wounds
or burns of the soft tissues, medical comorbidity and poor
bone quality, such as in severe osteoporosis.
Fracture morphology takes into account only the most
severely damaged fractures, scoring from 1, compression,
to 4, distraction fracture, while burst and translational/
rotational injuries score 2 and 3, respectively.
Neurological injury values range from 0 in case of
normal neurological status (ASIA type E) to 3 points in
case of incomplete spinal cord injury (ASIA B-D) or cauda
equina syndrome, while complete spinal cord (ASIA A)
or nerve root injury scores 2. Because of this component,
a radiologist is unable to completely classify according to

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780 Ruiz Santiago et al. Role of imaging in thoracolumbar fractures

A B C

Figure 9 Injuries of the PLC. (A) Intact posterior ligament complex (arrow); (B) indeterminate injury (arrow); (C) complete injury (arrow).

A B C

D E F

Figure 10 Type A fractures of the Arbeitsgemeinschaft für Osteosynthesefragen Spine Thoracolumbar Injury Classification and Severity
score (AOSpine-TLICS). (A) 0 fracture affects only the transverse or spinous processes of the spine; (B) A1 is a wedge compression
fracture without involvement of posterior wall of the vertebral body; (C) A2 fracture is a pincer or split fracture of both endplates without
involvement of the posterior vertebral body; (D) A3 is a burst fracture affecting a single endplate; (E) A4 fracture is a complete burst fracture
affecting both endplates; (F) Sagittally oriented fractures of the lamina are typical for stable burst fractures.

TLICS, as information on neurological injury is needed.
Posterior ligament complex injury scores 0 when intact,
2 when the lesion is doubtful or indeterminate, and 3
when the injury is evident (Figure 9). Assessment of PLC
is important because its failure significantly influences the
severity of the fracture (52). In a recent study MRI increased
the severity of CT score of TL fractures in 31% of patients
and in 22% changed the indication for conservative
treatment (score <5 points) to indication for surgery (score
≥5 points) (53).
A new comprehensive modified AO classification system
has recently been proposed, the AOSpine-TLICS (54). It
takes the best of the Magerl and TLICS methods trying
to overcome the limitations of each. The new system
only scores fracture morphology and neurologic status,
but relevant patient-specific modifiers are considered in
therapeutic decisions. Fracture morphology is classified
in 3 main types of injury: Type A is a compression injury
without involvement of PLC and scores 0 (A0) to 5 (A4)
(Figure 10). The more severe subtypes, A3 and A4, include
vertebral body burst fractures with retropulsion of the
posterior vertebral wall without disruption of the PLC and,
therefore, considered stable. Fractures of the posterior arch
are vertically oriented.

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Quantitative Imaging in Medicine and Surgery, Vol 6, No 6 December 2016
A B
C D
Figure 11 Type B fractures of the Arbeitsgemeinschaft für
Osteosynthesefragen Spine Thoracolumbar Injury Classification
and Severity score (AOSpine-TLICS). (A) B1 is a monosegmental
osseous injury with damage of the posterior tension band; (B) B2
fracture with ligamentous posterior tension band injury; (C) B2
fracture with bony posterior tension band injury; (D) B3 fracture
is an anterior tension band injury. In this case, secondary to
ankylosing spondylitis.
In type B injuries there is damage of so-called the
tension bands; that is, the PLC or the anterior longitudinal
ligament. Fracture extension through the posterior
elements is horizontally oriented and disrupts the
stability of the spine. They can be a monosegmental bony
posterior tension band injury, B1, that scores 5, a mono
or multisegmental bony and/or ligamentary failure of
the posterior tension band, B2, that scores 6, or injuries
of the anterior longitudinal ligament, B3, that scores 7
(Figure 11). B3 injuries occur particularly in the ankylosed
spine, maintaining an intact posterior element hinge that
prevent gross displacement (55). Type C is a translation/
displacement injury and scores 8. Neurological injuries are
scored 0 to 4 according to the severity. Assessment of PLC
is now included among modifiers and score 1 when present
or indeterminate on MR images. Patients with more than
5 points in this score system should undergo surgical
intervention (56).
© Quantitative Imaging in Medicine and Surgery. All rights reserved.
781
Take home messages: radiological report with
quantitative information influences treatment
Findings and measurements in the radiological report
should be preferably included in agreement with referring
orthopedic surgeons. Radiologists need to describe the
anatomy of the fracture based on the primary types of
Denis’ classification (compression, burst, flexion-distraction
and fracture-dislocation) (31), and finally classify it
according to recent version of AOspine thoracolumbar
spine Injury classification system (54). This score strongly
influences therapeutic choice. Patients with more than
five points in this score system should undergo surgical
intervention (56). That means that all B2, B3 and C type
fractures have to be managed surgically, except if there
is medical contraindication. Surgical or non-surgical
treatment is acceptable for A4 and B1 fractures. The rest
of the fractures can be managed conservatively, except
when neurological or other clinical modifiers increase score
severity.
Basic radiographic measurements include the degree
of vertebral wedging (local Kyphosis) and millimeters or
percentage of vertebral height loss in case of compression
fractures. It should be noted that loss of anterior vertebral
body height >50% and local vertebral kyphotic angulation
>30º–35º can be an indication for surgery (1).
In burst fractures, information about the degree of
canal stenosis should be added. It can be reported as a
percentage, although the influence of the degree of stenosis
in neurological damage varies between vertebral levels (25).
Nevertheless, a sagittal-transverse diameter ratio <0.40 is
highly associated to neurological injury (24).
In more severe types of fractures, the degree of
translation and widening of the interspinous distance can
also be reported. Vertebral translation greater than 3.5 mm
has been reported to be associated with PLC injury (7).
Regarding interspinous distance, variations of up to 7 mm
can be normal and 20% of widening is considered as sign of
an unstable PLC, requiring surgical treatment (8).
In case for which extension CT and non-extension
radiographs are available, the degree of kyphotic correction
as a sign of vertebral instability can be predicted (49).
MRI is mainly indicated when doubts about damage
severity and treatment decisions persist after CT evaluation
of the fracture. It can correlate clinical neurological findings
with the severity and extension of spinal cord damage,
and the presence and severity of PLC injury (57). PCL
integrity can change treatment to conservative therapy or to
qims.amegroups.com Quant Imaging Med Surg 2016;6(6):772-784
782
minimally invasive surgery (4).
Acknowledgements
None.
Footnote
Conflict of Interest: The authors have no conflicts of interest
to declare.
References
1. Alpantaki K, Bano A, Pasku D, Mavrogenis AF,
Papagelopoulos PJ, Sapkas GS, Korres DS, Katonis P.
Thoracolumbar burst fractures: a systematic review of
management. Orthopedics 2010;33:422-29.
2. DeWald RL. Burst fractures of the thoracic and lumbar
spine. Clin Orthop Relat Res 1984;189:150-61.
3. Gertzbein SD. Scoliosis Research Society. Multicenter
spine fracture study. Spine (Phila Pa 1976) 1992;17:528-40.
4. Rajasekaran S, Kanna RM, Shetty AP. Management of
thoracolumbar spine trauma: An overview. Indian J Orthop
2015;49:72-82.
5. Kelly RP, Whitesides TE Jr. Treatment of lumbodorsal
fracture-dislocations. Ann Surg 1968;167:705-17.
6. Anderson MW. Imaging of Thoracic and Lumbar Spine
Fractures. Seminars in Spine Surgery 2010;22:8-19.
7. Radcliff K, Su BW, Kepler CK, Rubin T, Shimer AL,
Rihn JA, Harrop JA, Albert TJ, Vaccaro AR. Correlation
of Posterior Ligamentous Complex Injury and
Neurological Injury to Loss of Vertebral Body Height,
Kyphosis, and Canal Compromise. Spine (Phila Pa 1976)
2012;37:1142-50.
8. Neumann P, Wang Y, Kärrholm J, Malchau H, Nordwall
A. Determination of inter-spinous process distance in
the lumbar spine Evaluation of reference population
to facilitate detection of severe trauma. Eur Spine J
1999;8:272-8.
9. Masharawi Y, Salame K, Mirovsky Y, Peleg S, Dar G,
Steinberg N, Hershkovitz I. Vertebral body shape variation
in the thoracic and lumbar spine: characterization of its
asymmetry and wedging. Clin Anat 2008;21:46-54.
10. Matsumoto M, Okada E, Kaneko Y, Ichihara D, Watanabe
K, Chiba K, Toyama Y, Fujiwara H, Momoshima S,
Nishiwaki Y, Hashimoto T, Takahata T. Wedging
of vertebral bodies at the thoracolumbar junction in
asymptomatic healthy subjects on magnetic resonance
© Quantitative Imaging in Medicine and Surgery. All rights reserved.
Ruiz Santiago et al. Role of imaging in thoracolumbar fractures
imaging. Surg Radiol Anat 2011;33:223-28.
11. Gaca AM, Barnhart HX, Bisset GS 3rd. Evaluation of
wedging of lower thoracic and upper lumbar vertebral
bodies in the pediatric population. AJR Am J Roentgenol
2010;194:516-20.
12. Genant HK, Wu CY, van Kuijk C, Nevitt MC. Vertebral
fracture assessment using a semiquantitative technique. J
Bone Miner Res 1993;8:1137-48.
13. Szulc P, Munoz F, Marchand F, Delmas PD.
Semiquantitative evaluation of prevalent vertebral
deformities in men and their relationship with osteoporosis:
the MINOS Study. Osteoporos Int 2001;12:302-10.
14. McKiernan FE. The broadening spectrum of osteoporotic
vertebral fracture. Skeletal Radiol 2009;38:303-8.
15. Griffith JF. Identifying osteoporotic vertebral fracture.
Quant Imaging Med Surg 2015;5:592-602.
16. Diacinti D, Guglielmi G. Vertebral Morphometry. Radiol
Clin N Am 2010;48:561-75.
17. Keynan O, Fisher CG, Vaccaro A, Fehlings MG, Oner
FC, Dietz J, Kwon B, Rampersaud R, Bono C, France
J, Dvorak M. Radiographic measurement parameters in
thoracolumbar fractures: a systematic review and consensus
statement of the spine trauma study group. Spine (Phila Pa
1976) 2006;31:E156-65.
18. Farcy JP, Veidenbaum M, Glassman S. Sagittal index in
management of thoracolumbar burst fractures. Spine (Phila
Pa 1976) 1990;15:958-65.
19. Meena S, Sharma P, Chowdhury B. Management
of Thoracolumbar Fractures. Indian J Neurosurg
2015;4:56-62.
20. Sheridan R, Peralta R, Rhea J, Ptak T, Novelline
R. Reformatted visceral protocol helical computed
tomographic scanning allows conventional radiographs
of the thoracic and lumbar spine to be eliminated in
the evaluation of blunt trauma patients. J Trauma
2003;55:665-69.
21. Campbell SE, Phillips CD, Dubovsky E, Cail WS, Omary
RA. The value of CT in determining potential instability of
simple wedge-compression fractures of the lumbar spine.
Am J Neuroradiol 1995;16:1385-92.
22. Ballock RT, Mackersie R, Abitbol JJ, Cervilla V, Resnick
D, Garfin SR. Can burst fractures be predicted from plain
radiographs? J Bone Joint Surg Br 1992;74:147-50.
23. Dai LY, Wang XY, Jiang LS, Jiang SD, Xu HZ. Plain
Radiography Versus Computed Tomography Scans in
the Diagnosis and Management of Thoracolumbar Burst
Fractures. Spine (Phila Pa 1976) 2008;33:E548-52.
24. Vaccaro AR, Nachwalter RS, Klein GR, Sewards JM,
qims.amegroups.com Quant Imaging Med Surg 2016;6(6):772-784
Quantitative Imaging in Medicine and Surgery, Vol 6, No 6 December 2016
Albert TJ, Garfin SR. The significance of thoracolumbar
spinal canal size in spinal cord injury patients. Spine (Phila
Pa 1976) 2001;26:371-76.
25. Hashimoto T, Kaneda K, Abumi K. Relationship between
traumatic spinal canal stenosis and neurologic deficits
in thoracolumbar burst fractures. Spine (Phila Pa 1976)
1988;13:1268-72.
26. Berry GE, Adams S, Harris MB, Boles CA, McKernan
MG, Collinson F, Hoth JJ, Meredith JW, Chang MC,
Miller PR. Are plain radiographs of the spine necessary
during evaluation after blunt trauma? Accuracy of
screening torso computed tomography in thoracic/lumbar
spine fracture diagnosis. J Trauma 2005;59:1410-13.
27. Diaz JJ Jr, Cullinane DC, Altman DT, Bokhari F, Cheng
JS, Como J, Gunter O, Holevar M, Jerome R, Kurek SJ
Jr, Lorenzo M, Mejia V, Miglietta M, O'Neill PJ, Rhee P,
Sing R, Streib E, Vaslef S; EAST Practice Management
Guideline Committee. Practice management guidelines for
the screening of thoracolumbar spine fracture. J Trauma
2007;63:709-18.
28. Bondurant FJ, Cotler HB, Kulkarni MV, McArdle CB,
Harris JH Jr. Acute spinal cord injury. A study using
physical examination and magnetic resonance imaging.
Spine (Phila Pa 1976) 1990;15:161-8.
29. Schaefer DM, Flanders AE, Osterholm JL, Northrup BE.
Prognostic significance of magnetic resonance imaging
in the acute phase of cervical spine injury. J Neurosurg
1992;76:218-23.
30. Pizones J, Izquierdo E, Alvarez P, Sánchez-Mariscal F,
Zúñiga L, Chimeno P, Benza E, Castillo E. Impact of
magnetic resonance imaging on decision making for
thoracolumbar traumatic fracture diagnosis and treatment.
Eur Spine J 2011;20:S390-6.
31. Denis F. The three column spine and its significance in the
classification of acute thoracolumbar spinal injuries. Spine
(Phila Pa 1976) 1983;8:817-31.
32. Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S.
A comprehensive classification of thoracic and lumbar
injuries. Eur Spine J 1994;3:184-201.
33. Bernstein MP, Mirvis SE, Shanmuganathan K. Chance-
type fractures of the thoracolumbar spine: imaging analysis
in 53 patients. AJR Am J Roentgenol 2006;187:859-68.
34. Nagel DA, Koogle TA, Piziali RL, Perkash I. Stability of
the upper lumbar spine following progressive disruptions
and the application of individual internal and external
fixation devices. J Bone Joint Surg Am 1981;63:62-70.
35. Lingawi SS. The naked facet sign. Radiology
2001;219:366-7.
© Quantitative Imaging in Medicine and Surgery. All rights reserved.
783
36. Cooper C, Atkinson EJ, O’Fallon WM, Melton LJ.
Incidence of clinically diagnosed vertebral fractures: a
population based study in Rochester, Minnesota, 1985-
1989. J Bone Miner Res 1992;7:221-27.
37. Ruiz Santiago F, Santiago Chinchilla A, Guzmán Álvarez L,
Pérez Abela AL, Castellano García Mdel M, Pajares López
M. Comparative review of vertebroplasty and kyphoplasty.
World J Radiol 2014;6:329-43.
38. Ruiz Santiago F, Castellano García MM, Guzmán Álvarez
L, Tello Moreno M. Computed tomography and magnetic
resonance imaging for painful spinal column: contributions
and controversies. Radiologia 2011;53:116-33.
39. Burrell HL. I. Fracture of the spine: a summary of all the
cases (244) which were treated at the Boston City Hospital
from 1864 to 1905. Ann Surg 1905;42:481-506.
40. Böhler L. Die techniek der knochenbruchbehandlung
im grieden und im kriege. Vienna, Austria: Verlag von
Wilheim Maudrich; 1930, 9-11.
41. Watson-Jones R. The results of postural reduction
of fractures of the spine. J Bone Joint Surg Am
1938;20:567-86.
42. Nicoll EA. Fractures of the dorso-lumbar spine. J Bone
Joint Surg Br 1949;31B:376-94.
43. Holdsworth F. Fractures, dislocations, and fracture-
dislocations of the spine. J Bone Joint Surg Am
1970;52:1534-51.
44. Decoulx P, Rieunau G. Fractures of the dorsolumbar
spine without neurological disorders. Rev Chir Orthop
Reparatrice Appar Mot 1958;44:254-322.
45. Roy-Camille R, Saillant G, Marie-Anne S, Mamoudy P.
Treatment of vertebral fractures and dislocations of the
thoracolumbar area. Orthopade 1980;9:63-8.
46. James KS, Wenger KH, Schlegel JD, Dunn HK.
Biomechanical evaluation of the stability of thoracolumbar
burst fractures. Spine 1994;19:1731-40.
47. McAfee PC, Yuan HA, Fredrickson BE, Lubicky JP. The
value of computed tomography in thoracolumbar fractures.
An analysis of one hundred consecutive cases and a new
classification. J Bone Joint Surg Am 1983;65:461-73.
48. McCormack T, Karaikovic E, Gaines RW. The load
sharing classification of spine fractures. Spine (Phila Pa
1976) 1994;19:1741-4.
49. Nakamae T, Fujimoto Y, Yamada K, Hashimoto T,
Olmarker K. Efficacy of Percutaneous Vertebroplasty in
the Treatment of Osteoporotic Vertebral Compression
Fractures with Intravertebral Cleft. Open Orthop J
2015;9:107-13.
50. Vaccaro AR, Lehman RA Jr, Hurlbert RJ, Anderson PA,
qims.amegroups.com Quant Imaging Med Surg 2016;6(6):772-784
784
Harris M, Hedlund R, Harrop J, Dvorak M, Wood K,
Fehlings MG, Fisher C, Zeiller SC, Anderson DG, Bono
CM, Stock GH, Brown AK, Kuklo T, Oner FC. A new
classification of thoracolumbar injuries: the importance
of injury morphology, the integrity of the posterior
ligamentous complex, and neurologic status. Spine (Phila
Pa 1976) 2005;30:2325-33.
51. Harrop JS, Vaccaro AR, Hurlbert RJ, Wilsey JT, Baron
EM, Shaffrey CI, Fisher CG, Dvorak MF, Oner FC, Wood
KB, Anand N, Anderson DG, Lim MR, Lee JY, Bono CM,
Arnold PM, Rampersaud YR, Fehlings MG. Intrarater
and interrater reliability and validity in the assessment
of the mechanism of injury and integrity of the posterior
ligamentous complex: a novel injury severity scoring
system for thoracolumbar injuries. Invited submission
from the Joint Section Meeting on Disorders of the Spine
and Peripheral Nerves, March 2005. J Neurosurg Spine
2006;4:118-22.
52. Machino M, Yukawa Y, Ito K, Kanbara S, Morita D, Kato
F. Posterior ligamentous complex injuries are related to
fracture severity and neurological damage in patients with
acute thoracic and lumbar burst fractures. Yonsei Med J
2013;54:1020-5.
53. Winklhofer S, Thekkumthala-Sommer M, Schmidt D,
Rufibach K, Werner CM, Wanner GA, Alkadhi H, Hodler
J, Andreisek G. Magnetic resonance imaging frequently
Cite this article as: Ruiz Santiago F, Tomás Muñoz P,
Moya Sánchez E, Revelles Paniza M, Martínez Martínez A,
Pérez Abela AL. Classifying thoracolumbar fractures: role of
quantitative imaging. Quant Imaging Med Surg 2016;6(6):772-
784. doi: 10.21037/qims.2016.12.04
© Quantitative Imaging in Medicine and Surgery. All rights reserved.
Ruiz Santiago et al. Role of imaging in thoracolumbar fractures
changes classification of acute traumatic thoracolumbar
spine injuries. Skeletal Radiol 2013;42:779-86.
54. Vaccaro AR, Oner C, Kepler CK, Dvorak M, Schnake
K, Bellabarba C, Reinhold M, Aarabi B, Kandziora F,
Chapman J, Shanmuganathan R, Fehlings M, Vialle
L; AOSpine Spinal Cord Injury & Trauma Knowledge
Forum. AOSpine thoracolumbar spine injury classification
system: fracture description, neurological status, and key
modifiers. Spine (Phila Pa 1976) 2013;38:2028-37.
55. Novella Navarro M, Muñoz Gómez MM, Santiago
FR, Álvarez ER. Uncommon localization of pathologic
vertebral fracture in ankylosing spondylitis. Joint Bone
Spine 2015;82:371.
56. Vaccaro AR, Schroeder GD, Kepler CK, Cumhur Oner F,
Vialle LR, Kandziora F, Koerner JD, Kurd MF, Reinhold
M, Schnake KJ, Chapman J, Aarabi B, Fehlings MG,
Dvorak MF. The surgical algorithm for the AOSpine
thoracolumbar spine injury classification system. Eur Spine
J 2016;25:1087-94.
57. Rajasekaran S, Vaccaro AR, Kanna RM, Schroeder GD,
Oner FC, Vialle L, Chapman J, Dvorak M, Fehlings M,
Shetty AP, Schnake K, Maheshwaran A, Kandziora F. The
value of CT and MRI in the classification and surgical
decision-making among spine surgeons in thoracolumbar
spinal injuries. Eur Spine J 2016. [Epub ahead of print].
qims.amegroups.com Quant Imaging Med Surg 2016;6(6):772-784